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Abstract
The metastasis of neoplastic cells from their site of origin to distant anatomic locations continues to be the principal cause of death from malignant tumors, and that fact has been recognized by physicians for over a century. After the work done by Halsted in the treatment of breast cancer in the 1880s, accepted surgical canon held that metastasis occurred in a linear fashion, with centrifugal "growth in continuity" from the primary neoplasm that first involved regional lymph nodes. Those structures were considered to then be the sources of more distant, visceral metastases. With that premise in mind, radical and "ultra-radical" surgical procedures were devised to remove as many lymph nodes as possible in the treatment of carcinomas and melanomas. However, such interventions were ineffective in altering tumor-related mortality. This review considers the details of the historical material just mentioned. It also reviews currently-held concepts on biological mechanisms of metastasis, the "sentinel" lymph node biopsy technique, and the important topic of metastatic tumor "dormancy" as the cause of surgical treatment failure. Finally, predictive models of tumor behavior are discussed, which are based on gene signatures. These will likely be the key to identifying malignant lesions of low surgical stage that ultimately prove fatal through later manifestation of metastasis.
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Affiliation(s)
- Mark R Wick
- Division of Surgical Pathology & Cytopathology, Department of Pathology, University of Virginia Medical Center, Room 3020, 1215 Lee Street, Charlottesville, VA 22908-0214, United States.
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Orang E, Marzony ET, Afsharfard A. Predictive role of tumor size in breast cancer with axillary lymph node involvement - can size of primary tumor be used to omit an unnecessary axillary lymph node dissection? Asian Pac J Cancer Prev 2014; 14:717-22. [PMID: 23621225 DOI: 10.7314/apjcp.2013.14.2.717] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Breast cancer is the most common cancer among women worldwide. The aim of this study was to investigate the relationship between tumor size and axillary lymph node involvement (ALNI) in patients with invasive lesions, to find the best candidates for a full axillary dissection. Additionally, we evaluated the association between tumor size and invasive behavior. The study was based on data from 789 patients with histopathologically proven invasive breast cancer diagnosed in Shohada University hospital in Tehran, Iran (1993-2009). Cinical and histopathological characteristics of tumors were collected. Patients were divided into 6 groups according to primary tumor size: group I (0.1-≤1cm), II (1.1-≤2cm), III (2.1-≤3cm), IV (3.1-≤4cm), V (4.1-≤5cm) and VI (>5cm). The mean(±SD) size of primary tumor at the time of diagnosis was 3.59±2.69 cm that gradually declined during the course of study. There was a significant correlation between tumor size and ALNI (p<0.001). A significant positive correlation between primary tumor size and involvement of surrounding tissue was also found (p<0.001). The mean number of LNI in group VI was significantly higher than other groups (p<0.05).We observed more involvement of lymph nodes, blood vessels, skin and areola-nipple tissue with increase in tumor size.We found 15.3% overall incidence of ALNI in tumors ≤2 cm, indicating the need for more investigation to omit full axillary lymph node dissection with an acceptable risk for tumors below this diameter. While in patients with tumors ≥2 cm, 84.3% of them had nodal metastases, so the best management for this group would be a full ALND. Tumor size is a significant predictor of ALNM and involvement of surrounding tissue, so that an exact estimation of the size of primary tumor is necessary prior to surgery to make the best decision for management of patients with invasive breast cancer.
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Affiliation(s)
- Elahe Orang
- Islamic Azad University, Tehran Medical Branch, Tehran, Iran.
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Kothari MS, Rusby JE, Agusti AA, MacNeill FA. Sentinel lymph node biopsy after previous axillary surgery: A review. Eur J Surg Oncol 2011; 38:8-15. [PMID: 22032909 DOI: 10.1016/j.ejso.2011.10.003] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2011] [Revised: 09/13/2011] [Accepted: 10/10/2011] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND The utility of axillary lymph node dissection (ALND) in the management of breast cancer is currently under close scrutiny. At primary diagnosis the use of sentinel lymph node biopsy (SLNB) has restricted ALND for proven nodal disease, however the management of the axilla at local (in-breast) relapse is less clearly defined with many undergoing routine ALND. This review examines the role of SLNB in the re-operative setting with the objective of developing an axillary management algorithm for use at in-breast local relapse, and restricting ALND to node-positive recurrent cancers. METHODS We reviewed published reports of SLNB at local relapse in women who had previously undergone axillary surgery either as lymph node biopsy, SLNB, axillary sampling (AS) or axillary lymph node dissection (ALND). RESULTS There have been no randomised trials. Six reports with 327 cases were identified; of which 61% (199/327) had previous SLNB or ALND with <9 nodes removed. There was an overall successful sentinel lymph node (SLN) localisation at re-operation of 69% (227/327), range of 51-100%. In patients who have previously had limited axillary surgery (<9 nodes removed), the rate of successful SLN localisation was 83% (165/199), range of 68-100% and 142/165 (86%, range 80-100%) were node negative. In these highly selected patients no axillary recurrences were noted in those who had a negative SLN at re-operation after 26-46 months follow up. CONCLUSION SLNB at in-breast relapse is feasible and safe with successful localisation related to the extent of previous axillary surgery.
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Affiliation(s)
- M S Kothari
- Academic Breast Surgery Unit, Royal Marsden Hospital, Fulham Road, London SW3 6JJ, UK.
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Gerber B, Heintze K, Stubert J, Dieterich M, Hartmann S, Stachs A, Reimer T. Axillary lymph node dissection in early-stage invasive breast cancer: is it still standard today? Breast Cancer Res Treat 2011; 128:613-24. [PMID: 21523451 DOI: 10.1007/s10549-011-1532-0] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2010] [Accepted: 04/16/2011] [Indexed: 12/26/2022]
Abstract
Evaluation of axillary lymph node status by sentinel lymph node biopsy (SLNB) and complete axillary lymph node dissection (ALND) are an inherent part of breast cancer treatment. Increased understanding of tumor biology has changed the prognostic and therapeutic impact of lymph node status. Non-invasive imaging techniques like axillary ultrasound, FDG-PET, or MRI revealed moderate sensitivity and high specificity in evaluation of lymph node status. Therefore, they are not sufficient for lymph node staging. Otherwise, the impact of remaining micrometastases and even macrometastases for prognosis and treatment decisions is overestimated. Considering tumor biology, the distinction of axillary metastases in isolated tumor cells (ITC, pN0(i+)); micrometastases (pN1mi), and macrometastases (pN1a) is not comprehensible. Increasing data support the thesis that remaining axillary metastases neither increase the axillary recurrence rate nor decrease overall survival. It is doubtful that axillary tumor cells are capable to complete the complex multistep metastatic process. If applied, axillary metastases are sensitive to systemic treatment and are targeted by postoperative tangential breast irradiation. Therefore, the controversy about the clinical relevance of tumor cell clusters or micrometastases in SLN is a sophisticated but not contemporary discussion. Currently, there is no indication for axillary surgery in elderly patients with favorable tumors and clinically tumor-free lymph nodes. Nonetheless, a rational and evidence-based approach to the management of clinically and sonographically N0 patients with planned breast-conserving surgery and limited tumor size is needed now.
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Affiliation(s)
- Bernd Gerber
- Department of Obstetrics and Gynecology, University of Rostock, Suedring 81, Rostock, Germany.
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Principles of Evidence-Based Medicine as Applied to Sentinel Lymph Node Biopsies. AJSP-REVIEWS AND REPORTS 2008. [DOI: 10.1097/pcr.0b013e31817a79d5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Aziz D, Gardner S, Pritchard K, Paszat L, Holloway CMB. Selective Application of Axillary Node Dissection in Elderly Women with Early Breast Cancer. Ann Surg Oncol 2006; 14:652-9. [PMID: 17151795 DOI: 10.1245/s10434-006-9092-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2006] [Revised: 06/29/2006] [Accepted: 06/29/2006] [Indexed: 11/18/2022]
Abstract
BACKGROUND Routine use of axillary lymph node dissection (ALND) has been questioned in elderly women. This study examines whether selective application of ALND in early stage breast cancer affects breast cancer-related survival. METHODS From the Surveillance, Epidemiology, and End Results (SEER) database, records of women >or=70 years of age with stage I or II breast cancer diagnosed between 1990 and 1995 were reviewed. Hazard ratios (HR) of cause-specific survival (CSS) between women receiving ALND and those who did not were compared. To minimize the potential for bias in the selection of women to receive ALND, HR of CSS was compared within propensity analysis deciles. RESULTS 20,151 women entered the analysis. Median follow up was 6 years (interquartile range 4.33-7.67 years). Seventy-five percent underwent ALND. Women with higher risk disease and younger age were more likely to undergo ALND. Five year unadjusted CSS in women who did and did not receive ALND was 92.1% and 90.6%, respectively, with a HR of 0.85, P = 0.002. Using the propensity analysis method, the adjusted HR for CSS associated with ALND was 0.89, P = 0.066. DISCUSSION After adjusting for differences in the probability of receiving ALND, no clinically or statistically significant difference in survival was observed among women who received ALND when compared with those who did not, although we could not account for differences in co-morbidity or use of systemic therapy between groups. CONCLUSION Surgeons select elderly women with early stage breast cancer for ALND with a negligible impact on CSS.
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Affiliation(s)
- Dalal Aziz
- Department of Surgery, University of Toronto, 100 College Street, M5G 1L5, Toronto, Canada
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van der Heiden-van der Loo M, Bezemer PD, Hennipman A, Siesling S, van Diest PJ, Bongers V, Peeters PHM. Introduction of sentinel node biopsy and stage migration of breast cancer. Eur J Surg Oncol 2006; 32:710-4. [PMID: 16765560 DOI: 10.1016/j.ejso.2006.04.001] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2005] [Accepted: 04/05/2006] [Indexed: 02/06/2023] Open
Abstract
AIM The purpose of this study was to examine in a large population based group of breast cancer patients treated in a regular care setting whether the introduction of the Sentinel Node Biopsy (SNB) led to detection of a higher percentage of patients with positive regional lymph nodes. METHODS The study includes 3665 early breast cancer patients, aged 30-85 years, diagnosed in the period 1997-2002 and registered at the Regional Cancer Registry of the Comprehensive Cancer Centre Middle Netherlands. During this period the SNB was introduced. The outcome of staging was compared for groups staged with or without SNB. A logistic regression model was used to adjust for age, calendar period and tumour size. RESULTS Overall a quarter of all patients over the period 1997-2002 underwent a SNB as method of lymphatic staging. The use of SNB clearly increased over time: from 2% in 1998 to 65% in 2002. The percentage node positive patients also rose significantly; before introduction of the SNB 30% of all patients were diagnosed with positive lymph nodes, and after SNB introduction this percentage was 40%. The increase is largely explained by the increase of patients diagnosed with only micrometastases. Adjustment did not change the results. CONCLUSION In conclusion, introduction of the SNB in early breast cancer led to significant upstaging of breast cancer patients treated in a regular care setting, due to the detection of more micrometastases. Since the relevance of micrometastases for long term survival is not yet known, this upstaging potentially led to over treatment of patients. On the other side, for some patients axillary lymph node dissection was prevented by the SNB procedure, preventing comorbidity.
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Rutgers EJT. Guidelines to assure quality in breast cancer surgery. Eur J Surg Oncol 2005; 31:568-76. [PMID: 16023942 DOI: 10.1016/j.ejso.2005.02.008] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2004] [Revised: 09/20/2004] [Accepted: 02/11/2005] [Indexed: 12/22/2022] Open
Abstract
The outcome of breast cancer surgery, with respect to cosmetic results, loco regional control and prognostic information from nodal staging, may vary substantially. Optimal breast cancer care starts with a proper surgical act, which can only be performed when optimal imaging and preoperative diagnosis are available. Next, on the basis of all peroperative findings, the right surgical procedure should be indicated after multidisciplinary consultation and discussion, keeping the objective of the final outcome in mind. The surgical act itself is best performed by an experienced surgeon who has maintained their experience after sufficient training. The outcome of the different procedures can be measured according to simple criteria and prospective registration. All possible surgical procedures, the indication-objectives, the training-objectives and outcome measures are described.
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Affiliation(s)
- E J Th Rutgers
- Department of Surgery, The Netherlands Cancer Institute/Antoni van Leeuwenhoek Hospital, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands.
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Litz CE, Beitsch PD, Roberts CA, Ewing G, Clifford E. Intraoperative cytologic diagnosis of breast sentinel lymph nodes in the routine, nonacademic setting: a highly specific test with limited sensitivity. Breast J 2005; 10:383-7. [PMID: 15327489 DOI: 10.1111/j.1075-122x.2004.21381.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Intraoperative determination of metastatic breast carcinoma in sentinel lymph nodes (SLNs) by cytologic methods has been proposed as highly specific and sensitive. Much of these data are derived from academic institutes with highly trained personnel and without axillary dissection occurring as a direct result of the intraoperative interpretation. This prospective study was undertaken to assess the sensitivity and specificity of cytology in the routine, private-practice, intraoperative setting. A total of 207 SLNs from 96 breast carcinoma patients were evaluated by intraoperative cytologic preparations by general surgical pathologists; positive results led to axillary lymphadenectomy. Ten nodes were positive by intraoperative cytology (IC). Permanent section analysis confirmed the presence of carcinoma in the IC-positive cases and documented carcinoma in 19 of the IC-negative cases. IC sensitivity and specificity were 34% and 100%, respectively. False-negative IC interpretations occurred in nodes with occult micrometastases (12 of 19 nodes) and lobular carcinoma (6 of 19 nodes). Only one of eight grossly positive sentinel nodes resulted in a false-negative IC. While near-perfect specificity and high sensitivity can be achieved with grossly positive sentinel nodes by IC, sensitivity is quite low in cases with micrometastatic and lobular carcinoma.
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MESH Headings
- Breast Neoplasms/diagnosis
- Breast Neoplasms/epidemiology
- Breast Neoplasms/pathology
- Carcinoma, Ductal, Breast/diagnosis
- Carcinoma, Ductal, Breast/epidemiology
- Carcinoma, Ductal, Breast/pathology
- Carcinoma, Lobular/diagnosis
- Carcinoma, Lobular/epidemiology
- Carcinoma, Lobular/pathology
- Diagnostic Tests, Routine
- Female
- Humans
- Intraoperative Care
- Lymphatic Metastasis
- Neoplasm Metastasis
- Predictive Value of Tests
- Prospective Studies
- Sensitivity and Specificity
- Sentinel Lymph Node Biopsy/methods
- Texas/epidemiology
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Affiliation(s)
- Craig E Litz
- Department of Pathology, St Paul Medical Center, Dallas, TX 75235, USA.
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Weigelt B, Verduijn P, Bosma AJ, Rutgers EJ, Peterse HL, van't Veer LJ. Detection of metastases in sentinel lymph nodes of breast cancer patients by multiple mRNA markers. Br J Cancer 2004; 90:1531-7. [PMID: 15083181 PMCID: PMC2409726 DOI: 10.1038/sj.bjc.6601659] [Citation(s) in RCA: 58] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Disseminated breast tumour cells in sentinel lymph nodes (SNs) were evaluated by quantitative real-time PCR and the sensitivity of this assay was compared to the routine histological analysis. First, several candidate marker genes were tested for their specificity in axillary lymph nodes (ALN) of 50 breast cancer patients and 43 women without breast cancer. The marker gene panel selected, designed to detect the mRNA of CK19, p1B, EGP2 and SBEM, was subsequently applied to detect metastases in 70 SNs that were free of metastases as determined by standard histological evaluation. Remarkably, seven negative SNs showed increased marker gene expression, suggesting the presence of (micro) metastases. Four of these seven SNs positive by real-time PCR proved to contain tumour deposits after careful review of the slides or further sectioning of the paraffin-embedded material. In three PCR positive SNs, however, no tumour cells were found by haematoxylin and eosin staining (H&E) and immunohistologically analysis. The quantitative real-time PCR assay with multiple mRNA markers for the detection of disseminated breast cancer cells in SNs thus resulted in an upstaging of SNs containing metastastic disease of 10% compared to the routine histological analysis. The application of this technique may be of clinical relevance, as it is suggested that micrometastatic disease in SNs are associated with further nodal non-SN metastases in breast cancer.
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Affiliation(s)
- B Weigelt
- Division of Experimental Therapy, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands
| | - P Verduijn
- Department of Surgery, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands
| | - A J Bosma
- Division of Experimental Therapy, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands
| | - E J Rutgers
- Department of Surgery, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands
| | - H L Peterse
- Division of Diagnostic Oncology, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands
| | - L J van't Veer
- Division of Experimental Therapy, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands
- Division of Diagnostic Oncology, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands
- Division of Experimental Therapy, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands. E-mail:
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Rucinski JC, Wise L. Optimal surgeon experience for breast cancer sentinel node biopsy: how can surgeons stay up-to-date? ACTA ACUST UNITED AC 2004; 61:259-63. [PMID: 15165763 DOI: 10.1016/j.cursur.2003.09.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- James C Rucinski
- Department of Surgery, Weill Medical College of Cornell University and New York Methodist Hospital, Brooklyn, New York, USA
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Comparison of Sentinel Lymph Node Biopsy and Axillary Node Dissection in the Treatment of Early-Stage Breast Cancer. Clin Breast Cancer 2003. [DOI: 10.1016/s1526-8209(11)70338-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Reintgen D, Pendas S, Giuliano R, Swor G, Pippas A, Jakub J. To Dissect or Not To Dissect?—That Is the Question. Clin Breast Cancer 2002. [DOI: 10.1016/s1526-8209(11)70262-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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